Clin Med
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Acute ST-segment-elevation myocardial infarction (STEMI) results from complete obstruction to coronary artery blood flow accompanied by the appearance of ST-segment-elevation on the electrocardiogram. Emergency treatment is required to restore coronary perfusion, thereby limiting the extent of damage to the myocardium and the likelihood of early death or future heart failure. This concise guideline summarises key recommendations from the National Institute for Health and Care Excellence clinical guideline on acute management of STEMI (CG167), of relevance to all healthcare professionals involved. Guidance is presented on choice of reperfusion strategies, procedural aspects, use of additional drugs before and alongside reperfusion therapies, and treatment of patients who are unconscious or in cardiogenic shock.
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Review
Physical restraint and the protection of the human rights of immigration detainees in hospitals.
Immigration detainees, like prisoners, are entitled to the same standard of healthcare as non-detained patients. When hospital attendance or admission is required, the priority for custodial staff (who for purposes of this article we refer to as 'escorts') is to prevent absconding. ⋯ Clinicians have professional obligations to all their patients and must object to any restraint methods that risk damaging the patient's right to confidentiality, treatment, health or the therapeutic relationship itself. The starting presumption is that restraints ought not to be used during treatment and only in the most exceptional cases ought escorts to be present during clinical examination or treatment.
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Blood transfusion is widely used in the management of acute upper gastrointestinal haemorrhage (AUGIH). Trial data suggests that excessive transfusion may be detrimental, yet overtransfusion remains commonplace. This study reports the impact of introducing a simple cross-match policy in a district general hospital, which resulted in a substantial fall in the prevalence of overtransfusion (odds ratio 0.43; 95% confidence interval 0.19-0.98), with potential patient benefits in terms of rebleeding, and a reduction in the total blood transfused from 162 to 121 units per 100 patients with AUGIH. For the cost of blood alone, this corresponds to projected savings across the NHS in England in excess of £2 million per annum.
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Melanoma-associated retinopathy is a rare paraneoplastic complication of metastatic cutaneous malignant melanoma. It may present years after the original diagnosis of melanoma. We describe a patient with this condition who presented with persistent visual symptoms.
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Immunoglobulin G4-related disease (IgG4-RD) is a systemic inflammatory condition that may involve any organ in the body, including the kidneys. However, renal parenchymal lesions are not seen frequently and the treatment strategy remains unclear. We describe a case of IgG4-related renal mass, which resolved spontaneously. ⋯ A careful 'watch-and-wait' approach was taken and at six months following initial presentation, the patient's symptoms had fully resolved and inflammatory markers had normalised. Repeat MRI showed almost complete resolution of the mass. We propose that a careful 'watch-and-wait' approach could be considered as an alternative to immune suppression for IgG4-related renal masses, especially if they are not causing symptoms or organ compromise.